My Name is:

My occupation is:

My favorite color is:

My least-favorite color is:

My favorite credit card number and expiration date is:

My worst habit would be:
Worrying
Overeating
Oversleeping
Drinking Hard Liquor
Smoking Crack Cocaine
All of the above

My biggest fear would be:
Plunging to death in a horrific plane crash
Being crushed to death in a catastrophic car crash
Suffering unmercifully from some pain-inflicting deadly disease
Having to sit through the director's cut of 'The Hottie and the Nottie'
All of the above

My total houehold income is:
$50,000 to $100,000
$100,000 to $200,000
More than $200,000
Less than $200,000

If you selected 'less than $200,000; would you be interested in receiving
information on how you can earn over $200,000 a year stuffing envelopes?
Yes No Not sure

Do you own your own home?
Yes
No
Not sure

If you selected 'Yes'; would you be interested in attending
a brief presentation for a time-share property offer?
Yes No Absolutely Not


The idea of being hypnotized:
Frightens me
Excites Me
Confuses me
Irritates Me
Fascinates Me
Angers Me
Puzzles Me
I am already hypnotized


For a limited time, Dr. VanderHawk is offering his services free to those
interested in overcoming their multitude of problems.
If you would like to receive periodic self-hypnosis sessions by way of e-mail,
simply submit your e-mail address in the space provided.
But please be patient. Due to the overwhelming response to Dr. VanderHawk's website,
it could take 6 to 8 months to receive your first e-mail.

Here is an example of a recent e-mail self-hypnosis session:
Hello and welcome from Dr. Spencer VanderHawk. It's time for your daily self-hypnosis session. Relax and assume a comfortable position. Take a deep breath. Exhale deeply. Take another deep breath. Take yet another, deeper breath. Exhale deeply twice. Take another deep, deep breath and hold it. Think of something pleasant. Now exhale slowly. Stop thinking of something pleasant. Now, you are hypnotized. Now, repeat the following suggestions in a calm, soothing, monotonous voice: I am no longer a miserable person. I am no longer filled with disgust and dreadfulness. I am no longer rude and cynical. I am no longer arrogant and egotistical. I am no longer obtuse and perfunctory. I am no longer querulous and splenetic. I am a happy person. I am a delightful person. I am sagacious! I have abundant energy to accomplish all of my goals. I am able to climb a tall tree, if I want to. I am able to clean out my hall closet. I will no longer waste my time visiting worthless websites. Thank you, Dr. VanderHawk, for helping me with my miserable life. I feel like I should send you a nice gift. Perhaps a nice fruit basket or a bottle of expensive wine. I will not forget to do this. I will not forget to do this. I will not forget to do this. At the count of three, I will no longer be hypnotized. One, two, three. There, now I am much better. Dr. Spencer VanderHawk wishes you a good day. DISCLAIMER: Dr. VanderHawk is not a licensed hypnotherapist. Nor is he an actual doctor. Nor is Dr. Spencer VanderHawk his real name. --end of message-- (PLEASE SLIDE THE BAR UP TO THE TOP TO BEGIN READING THE TEXT IN THIS BOX)

Sure, sign me up.

Thank you for allowing Dr. VanderHawk to help you.
And please remember not to operate heavy machinery while hypnotized.